Multidisciplinary Crisis Management of Cavernous Carotid Injury: The Value of Debrief and Independent Observation

Background: Simulation training for crisis management is a well-established training tool. Learner management of intraoperative crisis such as a major cerebrovascular bleed requires effective teamwork, communication, and implementation of key skill-sets at appropriate time points. This study establishes a first of a kind multidisciplinary simulation experience in which a neurosurgery and anesthesia resident team work together to manage an intraoperative crisis.

Methods: Prior to simulation, an expanded endonasal approach and right cavernous carotid injury was performed on a cadaveric head. A simulation mannequin was intubated and connected to the ventilator, and IV and arterial lines placed. Vital signs and ventilator settings were manipulated by the investigators based on three simulation case scenarios: cavernous carotid bleed in a patient with hypothyroidism, a patient with coronary artery disease, and a healthy patient. Teams consisting of 1 neurosurgery and 1 anesthesia resident performed the scenarios. Neurosurgery residents were tasked with obtaining vascular control with a muscle patch technique. Anesthesia residents were tasked with medical management. The cadaver’s right common carotid artery was cannulated and connected to a perfusion pump delivering pressurized simulated blood, and MAPs titrated by a perfusionist. Anesthesia residents were presented with vitals via an anesthesia machine monitor. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the team prior to beginning simulation. During each scenario, an independent reviewer evaluated learners on communication, crisis management algorithms, and implementation of appropriate skill sets. After completion of each scenario, residents were debriefed on their technique and performance based on their individual evaluation scores. Neurosurgery residents were given an anatomical exam pre- and post-simulation.

Results: During the first scenario, learners placed the muscle patch in the cavernous sinus to gain vascular control, with an average blood loss of 1129mL. After completion of the scenario, learners were debriefed on the technical and interprofessional aspects of their performance by an experienced observer, including performance of the muscle patch placement. During the second scenario, learners placed the muscle patch more specifically on the arterial injury site, and average blood lost was reduced to 875.8mL. Performance measured by an independent observer improved between the first and second scenarios. All resident teams were able to achieve vascular control at a MAP of 65mmHg. Neurosurgery learner scores on the anatomical exam improved from pre- (33.89%) to post-simulation (86.11%). All learners reported the simulation environment as realistic, and all neurosurgery learners reported developing an algorithm for managing vascular injury.

Conclusion: Realistic, first of kind, clinical simulation scenarios were presented to neurosurgery/anesthesia resident teams who worked together to manage an intraoperative crisis. This model employs the teaching of technical as well as clinical management of vascular injury, and communication skills during crisis management. Learners were effectively trained on crisis management, the importance of communication, and how to develop algorithms for future implementation in difficult scenarios, as reflected in resident post-simulation surveys. Learners were highly satisfied with the training experience and reported they would attend simulation again if offered in the future.